Distal Radius Fracture

yst ar S em ul : C c u s r u r e

M n

R Orthopedic & Muscular System:

i Litwic et al., Orthopedic Muscul Syst 2014, 3:3

ISSN: 2161-0533r o c

h h DOI: 10.4172/2161-0533.1000162 t r

O Current Research Review Article Open Access Distal radius fracture: Cinderella of the Osteoporotic Fractures Anna Litwic1, Lekarz, David Warwick2 and Elaine Dennison1* 1MRC Lifecourse Epidemiology Unit (University of Southampton), Southampton General Hospital, Southampton SO16 6YD, UK 2Orthopaedic Department, University Hospital Southampton, Southampton SO16 6UY, UK *Corresponding author: Elaine Dennison, MB BChir MA MSc PhD FRCP, Professor of Musculoskeletal Epidemiology and Honorary Consultant in Rheumatology, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK, Tel: +44 (0) 23 8077 7624; Fax: +44 (0) 23 8070 4021; E-mail: [email protected] Received date: Jun 13, 2014, Accepted date: Aug 4, 2014, Published date: Aug 11, 2014 Copyright: © 2014 Dennison E, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Osteoporosis is a systemic disorder characterized by low bone mass and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture. It has a significant impact on public health through the increased morbidity, mortality, and economic costs associated with fractures. The most common fracture sites are hip, spine and distal forearm. Among the different types of, the clinical and economic impact of hip and vertebral fractures have received most attention. There has been growing evidence, however, to suggest that the personal and public burden of fractures at other sites, including distal radius fracture, may have been under- recognized. This review will focus on the consequences of the Cinderella of the osteoporotic fractures – the distal radius fracture.

Keywords: Osteoporosis; Bone fragility; Fragility fractures the United States alone [6,7]. DRF fractures show a pattern of occurrence which differs from that of hip and vertebral fractures. Most Introduction DRF fractures occur in women. There is an increase in incidence in white women between the ages of 45 and 60 years, followed by a Osteoporosis is a systemic disorder characterized by low bone mass plateau. The plateau with age in women may be explained by mode of and microarchitectural deterioration of bone tissue with a consequent falls, which changes with age. Later in life a woman is more likely to increase in bone fragility and susceptibility to fracture [1]. It has a fall onto a hip than an outstretched hand as the speed and strength of significant impact on public health through the increased morbidity, extending the arm to protect other parts of the body during falls mortality, and economic costs associated with fractures. The most decreases with age. common fracture sites are hip, spine and distal forearm. In 2000, an estimated 9 million osteoporotic fractures occurred: 1.6 million at the Geographical location Women Men hip, 1.7 million at the forearm and 1.4 million clinical vertebral Oslo, Norway 767 202 fractures. Epidemiological studies from North America have estimated the lifetime risk of common fragility fractures to be 17.5% for hip Malmö, Sweden 732 178 fracture, 15.6% for clinically diagnosed vertebral fracture and 16 % for distal forearm fracture among white women aged 50 years [2]. Stockholm, Sweden 637 145 Corresponding risks among men are 6%, 5% and 2.5%. A study of Rochester, MN, USA 410 85 British fracture occurrence indicates a similar population risk in the United Kingdom. It indicates that one in two women 50 years old will Trent, UK 405 97 have an osteoporotic fracture in their remaining lifetime; the figure for Yugoslavia 228 95 men is one in five [3]. The combined annual costs of all osteoporotic fractures have been estimated to be 20 billion dollars in the United High calcium area 196 110 States and 30 billion euros in the European Union [4]. Low calcium area Among the different types of fragility fractures, the clinical and Oxford-Dundee, UK 309 73 economic impact of hip and vertebral fractures have received most Tottori, Japan 149 59 attention. There has been growing evidence, however, to suggest that the personal and public burden of fractures at other sites, including Singapore 59 63 distal radius fracture, may have been under-recognized [3,5]. This review will focus on the consequences of the Cinderella of the Adebajo, Nigeria 3 4 osteoporotic fractures – the distal radius fracture. Table 1: Age-adjusted incidence (per 100 000 per year) of DRF in Prevalence and Incidence of Distal Radius Fracture different populations of people aged 35 years or older (ref 4) Distal radius fractures (DRF) are the most common type of fracture Interestingly, significant variation in DRF fracture rates among among adults, with more than 640,000 cases reported during 2001 in women from different nations has been observed. Highest rates are

Orthopedic Muscul Syst Volume 3 • Issue 3 • 1000162 ISSN:2161-0533 OMCR, an open access journal Citation: Litwic A, Lekarz, Warwick D, Dennison E (2014) Distal radius fracture: Cinderella of the Osteoporotic Fractures. Orthopedic Muscul Syst 3: 162. doi:10.4172/2161-0533.1000162

Page 2 of 5 observed in Caucasian women, with lowest rates observed in African Health Impact of Distal Radius Fracture women and intermediate rates among Asian women [4] (Table 1). These differences are likely to represent a combination of genetic and Osteoporotic fractures account for 0.83% of the global burden of environmental differences. In all groups, an increase in absolute non-communicable disease worldwide and 1.75% in Europe where fracture numbers is anticipated due to demographic changes. osteoporotic fractures account for more disability-adjusted life years (DALYs) than many other chronic non-communicable diseases [3]. Data from the General Practice Research Database show that in a Although the functional impairment attributed to vertebral fractures woman’s lifetime risk of DRF fracture at 50 years old is 16.6%, and it and hip fractures has been well documented, the consequences of wrist falls to 10.4% at 70 years old. The incidence in men is low and does not fractures on functional decline have been less well studied. However, increase significantly with age (lifetime risk is 2.9% at age 50 years and available data suggest that the osteoporotic fractures at sites other than 1.4% at age 70 years) [8] (Table2). hip and spine (non-hip, non-vertebral [NHNV] fractures) may result in considerable morbidity and impact on health-related quality of life Forearm fracture Men Women Risk Ratio (HRQL) [11,15,22]. At 50 years old 2.9 16.6 5.7 In a recently published prospective, multinational, observational At 60 years old 2.0 14.0 7.0 cohort study of women over 55 years problems with self-care, mobility, activities, and pain/discomfort were measured at baseline At 70 years old 1.4 10.4 7.4 and after incident fracture [22]. Minor NHNV fractures, of which DRF

At 80 years old 1.1 6.9 5.8 fracture was reported to be the most common, were associated with increases in problems with mobility, self-care, activities and pain/ discomfort by 3%, 5%, 3% and 4% respectively. The proportion of Table 2: Remaining lifetime risk of DRF fracture (%) in men and women who reported a decrease in general health status between the women at 50 and 70 years of age Cited from ref 8 baseline and 1-year surveys was 21% in this fracture group. In this study incident DRF fractures had no effect on SF36 physical function Risk Factors or vitality. With regards to functionality, this findings contrast with the results of studies that assessed the effect of DRF in relation to Several factors associated with an increased risk of low-energy DRF specific tasks involving upper limb function. have been identified e.g. gender, vitamin D deficiency, seasonal variations, environmental conditions, medication and osteoporosis In the Study of Osteoporotic Fractures, the occurrence of a DRF [9-12]. Some factors such as low bone mineral density (BMD), age and increased the odds of having a clinically important functional decline history of previous low trauma fracture are strongly predictive of all by 48% (odds ratio 1.48, 95% confidence interval 1.04 to 2.12) [15]. types of fracture. Other risk factors are different in DRF than in Functional decline was defined by worsening ability to prepare meals, vertebral and hip fractures [13-16]. perform heavy housekeeping, climb 10 stairs, go shopping and get out of a car. The effect of DRF could be compared with other established Distal radius fractures often occur as a result of a fall in women with risk factors for functional decline such as falls, diabetes and arthritis. low bone mineral density who are relatively healthy and active. In a Similarly in the study by Gonzalez and colleagues, where measures prospective cohort study with 2578 participants, those with a used were speciﬁc for upper-extremity disability, individuals who moderately impaired walking ability were found to have a higher risk sustained DRF lost more HRQL and functionality 6 months after the of hip fracture (RR=1.8, 95% CI 1.2–2.7) but a lower risk of DRF fracture than those without a fracture [23]. (RR=0.4, 95% CI 0.2–0.8) compared with normal walking ability, adjusted for age and gender, Also going outdoors less than once a DRF also carries an increased risk for subsequent fractures [20, 24, week, compared with three times or more was associated with lower 25]. Data from the Rochester cohort suggest that in women with a risk of distal forearm fractures only (RR=0.3, 95% CI 0.1–0.9)[14]. DRF fracture, there is a 1.4-fold increase in the risk of a subsequent hip Similarly, in the Study of Osteoporotic Fractures women who had fracture [24]. These findings are consistent with the results of sustained DRF had significantly better functional status at baseline, a Scandinavian studies [20,25]. There is 1.5-fold increase in hip fractures higher gait speed (1.04 v 1.09 m/s, P<0.001) greater hip abduction seen among 2252 Swedish women age 40 years or more with a DRF strength and were able to stand up from a chair more quickly (5.498 v and a 1.8-fold increase among 1162 Danish women 20 years old or 5.776 s, P=0.006 , compared with their counterparts who did not have over with a DRF. The corresponding results for men in Rochester and wrist fractures [15]. Swedish cohorts are 2.7-fold and 2.3-fold increase in hip fractures respectively. Similarly other types of fractures are reported to be Environmental conditions may contribute to an increased risk of increased among Rochester women and men, with the greatest DRF in elderly women. The prevalence of those fractures which occur increase in risk for vertebral fractures. The standardized incidence indoors, is stable throughout the seasons [17], whereas outdoor ratios for fractures other than hip in women range from 1.0 to 5.6 and fractures have been shown to occur more frequent in the winter in men are higher from 2.7 to 10.7. months [17-19] especially, in snowy and icy conditions [20]. Reports suggest a higher incidence of fractures among city dwellers compared This is further supported by a recent study from Taiwan, in which with rural populations. In a Norwegian study the odds ratio for men 9,986 newly diagnosed DRF cases were identified between 2000 and sustaining a forearm fracture living in a city areas was 1.38 compared 2006 as the DRF cohort and 81,227 persons without a history of DRF with rural areas [21]. The findings for women were similar. Different as the comparison cohort [26]. The subjects were followed up for 1 lifestyles in urban populations compared with rural populations, might year after recruitment. In this study, patients with DRF had a much be a reason for this difference. greater risk for subsequent hip fracture within 1 year, compared with the control group (HR=3.45). The risk was the greatest (17 times) in

Page 3 of 5 the first month after the DRF. These findings emphasize the medications including psychotropic medications such as importance of prompt therapeutic action after diagnosis of DRF. antidepressants and benzodiazepines, and cardiovascular medications (especially those with hypotensive effects) and non-steroidal agents Complex regional pain syndrome post distal radius fracture may also increase the likelihood of falls, hence the need for their continuation should be regularly reviewed [32,33]. Environmental While DRFs are traditionally considered less significant than other factors such as poor lighting are another risk factor for falling. There is osteoporotic fractures, they are often associated with a poor outcome, little evidence, though, to suggest that nonpharmacological approaches In a review of 565 patients, Cooney et al reported a 31% overall lead to a beneficial reduction in falling or fracture risk [34]. complication rate [27]. A particular problem after DRF is Complex Regional Pain Syndrome (CRPS) otherwise known as reflex It is important to be able to identify those at highest risk of future sympathetic dystrophy, shoulder-hand syndrome and algodystrophy. fracture to best target preventative measures. Combining several risk CRPS is a syndrome of pain and widespread tenderness, allodynia, factors into a risk score may help to identify perimenopausal women at vasomotor instability, diffuse swelling and stiffness. In a study by high risk of distal forearm fracture. An example could be the FRAXtm Atkins et al, nine weeks after DRF, of the 60 patients studied, 24 had model [35]. Clinicians can input easily obtained clinical data to evidence of vasomotor instability, a recognised association of CRPS estimate risk. The estimate can be used alone or with BMD to enhance [28]. In a separate study, one hundred consecutive patients with fracture risk prediction. The application of this tool to clinical practice displaced DRF were reviewed ten years after the injury. At ten year requires a consideration of the fracture probability at which to follow up, 15% of those surviving had an unsatisfactory outcome. intervene. Sixty-two percent of those with an unsatisfactory result had objective Effective treatments are available that can significantly reduce the features of CRPS, compared with only 6% of those with a satisfactory risk of primary and secondary fragility fractures. Although the result [29]. In a recent prospective study the incidence of CRPS after association between prior fracture and future fracture is well DRF treated by closed reduction and cast immobilization was high at established in the current literature, it appears that few elderly patients 32.2% [30]. These data suggest that CRPS is a significant and relatively with previous fractures are receiving treatment to prevent further common complication of Colles’ fracture, that can have a major fractures. Approved pharmacological interventions for osteoporosis impact on patients’ quality of life. include bisphosphonates, strontium ranelate, raloxifene, denosumab and parathyroid hormone peptides. Of the available options, Mortality alendronate, risedronate, zoledronic acid, denosumab and strontium ranelate have been demonstrated to reduce vertebral, non-vertebral The increased mortality post hip and vertebral fractures have been and hip fractures. Because of this broader spectrum of anti-fracture well recognised and studied. In previous analyses minor fractures were efficacy these agents are generally regarded as preferred options in the not associated with an increase in mortality [24]. However, data from prevention of fractures in postmenopausal women. This distinction is the Dubbo osteoporosis epidemiology study suggest that all low- important because, as described above, once a fracture occurs, the risk trauma fractures are associated with an increased mortality risk for 5 of a subsequent fracture at any site is increased independent of BMD, years [31]. In this cohort of 659 non-hip, non-vertebral fractures and hence an intervention that covers all major fracture sites is (NHNV) (74% in women and 26% in men), these fractures preferable. contributed to 28% and 31% of all excess deaths in women and men, respectively. The age adjusted standardised mortality ratio was increased in minor fractures (including DRF) (SMRs, 1.42 [95% CI, Economic Cost 1.19-1.70] and 1.33 [95% CI, 0.99-1.80]) for both women and men, Osteoporosis is a highly prevalent disease and results in substantial respectively. Mortality rates for 5 years after minor fractures were costs both to the individual and to society through associated fragility higher than the general population for the age groups above 75 years. fractures. Patients who experience fractures often must rely on several Furthermore, not only does DRF carry an increased risk for health resources, with a signiﬁcant impact on the healthcare system. subsequent fractures as described above, but also that subsequent The annual cost of all osteoporotic fractures has been estimated at $20 fracture was associated with an increased mortality hazard ratio of 1.91 billion in the USA and $30 billion in the European Union [4]. In the (95% CI, 1.54-2.37) in women and 2.99 (95% CI, 2.11-4.24) in men UK alone, the annual cost to the health-care system from osteoporotic [31]. Mortality risk following a subsequent fracture then declined but fracture has been estimated at 1.7 billion pounds [36]. In Sweden, a beyond 5 years still remained higher than in the general population. prospective observational data collection study was undertaken to Given these findings, more attention should be given to non-hip, non- assess the cost and quality of life related to hip, vertebral and wrist vertebral fractures that constituted approximately 50% of all low- fracture (KOFOR) [37]. The mean fracture-related cost the year after trauma fractures and were associated with more than 40% of all DRF is estimated, in euros (€), at €2,147. The cost estimate in the first deaths. six months following the fracture is higher in the younger group of participants (50 – 64 years) than in those older than 65 years, €2,090 Prevention and Treatment Strategies and €1,891, respectively. The trend is reversed between 7 and 12 months after DRF with values of €299 and €507 in younger and older General prevention strategies include the avoidance of modifiable groups respectively [38]. The same study design has been used to risk factors such as smoking and excessive alcohol intake. As described investigate the cost and quality of life related to hip, vertebral and wrist above, the DRF often occur as a result of a fall in women with low fracture in an international perspective (The International Costs and BMD. Therefore, prevention of falls should be a priority in this patient Utilities Related to Osteoporotic Fractures Study (ICUROS)). The group. All patients should be assessed for risk factors for falls results from this study are awaited. including previous falls, fainting or episodes of loss of consciousness, muscle weakness, impaired balance and poor vision. Certain

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Orthopedic Muscul Syst Volume 3 • Issue 3 • 1000162 ISSN:2161-0533 OMCR, an open access journal